CLM-2026-007144
Summit Internal Medicine Associates, Internal Medicine. Service 2026-01-14 at office (POS 11). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Raymond Greene
- Member ID
- UHC-85120-03
- Date of birth
- 1961-03-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405005
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1811
- Coverage period
- 2023-02-01 to present
- Deductible
- $26.29 of $500.005%
- Out-of-pocket maximum
- $514.42 of $2,000.0026%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6465307315
- Network
- In network
- Rendering NPI
- 4570374148
- Location
- Dallas, TX · TIN 38-0331357
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93000 | Electrocardiogram with interpretation | 59 | 1 | 1 | $70.00 | $43.40 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 2 | $274.00 | $169.88 | — | — | Review |
| Totals | $344.00 | $213.28 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-244109
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005761 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-14: NULL (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Internal Medicine Associates (6465307315). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Internal Medicine Associates2026-01-14 14:06
Patient seen for type 2 diabetes mellitus with hyperglycemia. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-19 04:39
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-244109.pdf16 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-23 19:19The claim includes an office visit (99214) and an electrocardiogram (93000) with modifier 59, which is used to indicate a distinct procedural service. However, the clinical note [N1] and the operative note in the medical record [A1] both indicate that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, which is required to document a distinct procedural service according to the NCCI edit [R-ncci]. Therefore, the claim is denied with reason code CO97, as the office visit is included in the electrocardiogram service.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · 9d0c754a
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim includes an office visit (99214) and an electrocardiogram (93000) with modifier 59, which is used to indicate a distinct procedural service. However, the clinical note [N1] and the operative note in the medical record [A1] both indicate that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, which is required to document a distinct procedural service according to the NCCI edit [R-ncci]. Therefore, the claim is denied with reason code CO97, as the office visit is included in the electrocardiogram service.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.